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Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#20) out of 31 Emergency Department (ED) records reviewed from 05/2022 through 11/2022. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 5,587.

Findings included:

Review of the hospital's document titled, "Medical Staff Bylaws," dated 02/04/22, showed that a MSE will be provided for all patients requesting ED services and can be conducted by any of the following: a physician, an Advance Practice Nurse, a physician assistant, or an ED Registered Nurse (RN).

Review of the hospital's policy titled, "Ministry Wide EMTALA Requirements," dated 08/24/21, defined "comes to the ED" as when a patient presents to the ED in an ambulance, and a request has been made on their behalf, that the individual needs examination or treatment for a medical condition. If, prior to completion of the MSE, the covered person expresses the intent to leave the hospital, either the Qualified Medical Professional (QMP), triage nurse or other nurse in charge is responsible to encourage the covered person to remain and explain to the patient the risks of leaving and the benefits of the MSE. Hospital staff may not take any action to suggest that the patient leave the hospital prior to completion of a MSE. The hospital shall not discharge a covered person without having completed a MSE unless the covered person or his/her legal representative refuses to consent to the MSE, and the refusal is documented on a Mercy approved patient consent/refusal of treatment form. If a covered person (or legally responsible person) chooses to withdraw his or her request for examination or treatment, and if the staff is aware that the patient intends to leave prior to completion of the MSE, the following steps should be taken: Offer the covered person a MSE and treatment as may be required to identify and stabilize an EMC; and inform the covered person of the benefit of a MSE and of the risks of leaving prior to receiving a MSE; and take all reasonable steps to obtain the covered person's written informed refusal of the MSE on an approved form. Include documentation of the risks and benefits discussed with the patient in the patient's medical record.

Review of the hospital's undated policy titled, "EMTALA-Emergency Department," showed that a person coming to the ED in a ground ambulance has presented for examination and treatment for an EMC or psychiatric condition. A MSE is defined as a process required in determining with reasonable clinical confidence whether or not an EMC exists. The screening must be completed within the capabilities of the hospital, must determine what if any further medical examinations and/or treatments may be required to stabilize the patient, or to determine that the patient needs to be transferred to a different facility once the patient is stabilized per the capabilities of the transferring facility.

Review of Patient #20's ED record showed he presented to the ED on 07/24/22 at 1:29 PM by Emergency Medical Services (EMS) with a chief complaint of, "The patient had a physical and verbal altercation with staff, negative for suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideation (HI, thoughts or attempts to cause another's death), calm and cooperative at that time; patient will need new residence." The patient had a past medical history of intellectual disability (ID, below average intellectual functioning and problems with functioning independently), oppositional defiant behavior (ODD, a disorder marked by defiant and disobedient behavior to authority figures), morbid obesity (body weight that is greater than or equal to twice their ideal body weight and/or 100 pounds or more overweight), post-traumatic stress disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), schizoaffective disorder, bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances), and diabetes (a disease that affects how the body produces or uses blood sugar, and can cause poor healing). The patient's vital signs were stable. The patient's disposition was documented as left without being seen (LWBS) at 2:21 PM.


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Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#20) out of 31 Emergency Department (ED) records reviewed from 05/2022 through 11/2022. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 5,587.

Findings included:

Review of the hospital's document titled, "Medical Staff Bylaws," dated 02/04/22, showed that a MSE will be provided for all patients requesting ED services and can be conducted by any of the following: a physician, an Advance Practice Nurse, a physician assistant, or an ED Registered Nurse (RN).

Review of the hospital's policy titled, "Ministry Wide EMTALA Requirements," dated 08/24/21, defined "comes to the ED" as when a patient presents to the ED in an ambulance, and a request has been made on their behalf, that individual needs examination or treatment for a medical condition. If, prior to the completion of the MSE, the covered person expresses the intent to leave the hospital, either the Qualified Medical Professional (QMP), triage nurse or other nurse in charge is responsible to encourage the covered person to remain and explain to the patient the risks of leaving and the benefits of the MSE. Hospital staff may not take any action to suggest that the patient leave the hospital prior to completion of a MSE. The hospital shall not discharge a covered person without having completed a MSE unless the covered person or his/her legal representative refuses to consent to the MSE, and the refusal is documented on a Mercy approved patient consent/refusal of treatment form. If a covered person (or legally responsible person) chooses to withdraw his or her request for examination or treatment, and if the staff is aware that the patient intends to leave prior to completion of the MSE, the following steps should be taken: Offer the covered person a MSE and treatment as may be required to identify and stabilize an EMC; and inform the covered person of the benefit of a MSE and of the risks of leaving prior to receiving a MSE; and take all reasonable steps to obtain the covered person's written informed refusal of the MSE on an approved form. Include documentation of the risks and benefits discussed with the patient in the patient's medical record.

Review of the hospital's undated policy titled, "EMTALA-Emergency Department," showed that a person coming to the ED in a ground ambulance has presented for examination and treatment for an EMC or psychiatric condition. A MSE is defined as a process required in determining with reasonable clinical confidence whether or not an EMC exists. The screening must be completed within the capabilities of the hospital, must determine what if any further medical examinations and/or treatments may be required to stabilize the patient, or to determine that the patient needs to be transferred to a different facility once the patient is stabilized per the capabilities of the transferring facility.

Review of Patient #20's ED record showed he presented to the ED on 07/24/22 at 1:29 PM, by Emergency Medical Services (EMS) from Facility C (a residential facility with a locked behavioral health unit) with a chief complaint of, "The patient had a physical and verbal altercation with staff, negative for suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideation (HI, thoughts or attempts to cause another's death), calm and cooperative at that time; patient will need new residence. "The patient had a past medical history of intellectual disability (ID, below average intellectual functioning and problems with functioning independently), oppositional defiant behavior (ODD, a disorder marked by defiant and disobedient behavior to authority figures), morbid obesity (body weight that is greater than or equal to twice their ideal body weight and/or 100 pounds or more overweight), post-traumatic stress disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), schizoaffective disorder, bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances), and diabetes (a disease that affects how the body produces or uses blood sugar, and can cause poor healing). The patient's vital signs were stable. There was no triage (process of determining the priority of a patient's treatment based on the severity of their condition) documented. The patient's disposition was documented as left without being seen (LWBS) at 2:21 PM. There was no documentation of an against medical advice (AMA) form in the medical record.

Patient #20 presented to the ED on 07/24/22 from Facility C, by EMS, after an altercation with Facility C staff. The patient had a past history of mental health diagnoses, was not triaged and was in the ED lobby for less than an hour. He was allowed to leave and was in the care of his sister, without his medications, until he presented at Hospital B on 07/29/22.

During an interview and concurrent medical record review on 11/16/22 at 10:17 AM, Staff G, ED RN, stated that she remembered Patient #20 the day he arrived and she was the greeter (staff located at the front desk, either a nurse or paramedic, who received report from EMS, entered the patient's name and date of birth and chief complaint into the computer). Patient #20 came in by EMS on a stretcher, got off the stretcher and was ambulatory, had no medical complaints, and wanted to go home. She stated that the patient was alert and oriented to person, place, time and situation. She remembered that Patient #20 had his phone and he called his sister, and then told her that his sister was coming to pick him up. She was not sure where the patient had come from, perhaps a group home, and she was not aware that Patient #20 had a guardian. EMS gave verbal report to her, but she did not recall any specifics, and she did not recall if EMS had given her any additional paperwork.

During a telephone interview on 11/22/22 at 8:50 AM, Staff N, Paramedic, stated that the patient was picked up from Facility C, and was in the lobby with Facility C staff. He stated that he gave the greeter demographics for the patient, which included, who the patient was, where the patient came from and what chief complaint the patient was there for. He remembered that the patient was taken to the ED for aggressive behavior. He stated that he would have given Facility C's paperwork to the greeter when they arrived. He added that the greeter would have signed their computer after the patient was accepted. Patient #20 was then assisted off the stretcher and into a wheelchair with help of his partner. Staff N stated that it was not unusual for patients to have been left in the waiting room when the ED beds were full. He would not have expected a psychiatric patient to have been left in the waiting room, but many times the ED staff insisted the patient was left there.

During a telephone interview on 11/22/22 at 9:10 AM, Staff O, Emergency Medical Technician (EMT) stated that Patient #20 was picked up from Facility C due to agitation. When they picked up the patient, he was in the lobby, and they did not think he was a high risk patient. Once they arrived at the hospital ED, the patient was assisted off the stretcher and into a wheelchair. A patient was either taken to the mental health area or to triage depending on why they were there. She added that it was common for patients to have gone to the waiting room when the ED was busy.

During a group interview and concurrent review of the medical record for Patient #20, on 11/15/22 at 1:05 PM, with Staff E, Vice President Operations, Staff D, ED Nurse Manager, and Staff C, Emergency Services Director, a document from Facility C was shared with the group. The group was unaware that there were documents from Facility C that had been stickered and scanned into the medical record. They stated that they had interviewed Staff G, ED RN Greeter, after the event and she told them that the patient appeared alert and oriented, was placed in the waiting room, and then came to the desk and said that his sister was picking him up. Staff C and Staff D agreed that if a patient needed a psychiatric evaluation, the patient would have been taken directly to triage.

During an interview on 11/14/22 at 9:50 AM, Staff B, Senior Patient Safety Specialist, stated that it was common for EMS to bring patients who were then placed in the waiting room, but not if they had a psychiatric condition.

During a telephone interview on 11/15/22 at 3:45 PM, Staff J, ED Medical Director, stated that all patients who presented to the ED should have received a MSE.

During a telephone interview on 11/15/22 at 3:25 PM, Staff I, patient's sister, stated that she was called by her sister, who was a "drug addict," and told that she had picked the patient up from Mercy Hospital South and that he had been with her for the previous five days. She stated that she met her sister at a gas station to take her brother to Hospital B to have him checked out She was very upset that her sister had him and he had not received any of his medications for the past five days. She had not received a call from Facility C or Mercy Hospital South regarding the patients' whereabouts.

Review of Patient #20's ED medical record from Hospital B, showed he was a 28 year old male who presented on 07/29/22 at 1:37 PM, with a history of schizoaffective disorder, bipolar type, attention deficit/hyperactivity disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), mild developmental delay, diabetes and substance abuse, who was emergently discharged from Facility C. The patient was taken to Mercy Hospital South's ED five days prior, but LWBS, and the patient went without his medications for five days. The patient was discharged at 5:58 PM and was transported back to Facility C by EMS.




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